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ONE HAMILTON HEALTH PLACE

HAMILTON, NJ 08690

PATIENT RIGHTS: EXERCISE OF RIGHTS

Tag No.: A0129

Based on staff interview, review of two of two Emergency Department (ED) medical records of patients complaining of pain (#1, #10), and review of facility policies and procedures, it was determined the facility failed to ensure that: 1) all patients have adequate management of their pain; 2) a comprehensive pain assessment with a pain comfort level is performed.

Findings include:

Reference #1: Facility Policy titled, "Management of the Patient with Pain" states, "... The hospital recognizes and supports the adequate management of pain as a patient right. ... The goal of pain management is to improve the quality of life of patients experiencing pain by providing relief for those in acute and chronic pain through assessment, reassessment and pain management techniques."

Reference #2: Facility Policy titled, "Pain Management Policy" states, "... Registered Nurse performs an initial pain assessment, including assessment of the patient's and caregiver's knowledge about pain management. Patient's first positive finding of pain: The RN (Registered Nurse) and the patient mutually establish a Patient's Acceptable Comfort Goal/Level and document in the electronic information system. The RN performs and documents a comprehensive pain assessment that includes pain intensity using an appropriate pain scale, pain quality, location, onset, duration, aggravating and alleviating factors."

1) Upon review of Medical Record #1 on 07/29/22, the following was noted:

Patient #1 arrived to the ED on 06/13/22 at 8:07 PM. Nursing documentation indicated the patient had the following pain scores:

On 06/14/22 at 2:30 AM, the patient had a pain score of 5 (Moderate Pain).
On 06/14/22 at 4:30 AM, the patient had a pain score of 5 (Moderate Pain).
On 06/14/22 at 5:30 AM, the patient had a pain score of 5 (Moderate Pain).
On 06/14/22 at 6:30 AM, the patient had a pain score of 5 (Moderate Pain).
On 06/14/22 at 11:17 AM, the patient had a pain score of 8 (Severe Pain) of multiple pain sites.
On 06/14/22 at 11:34 AM, the patient had a pain score of 10 (Severe Pain).

ED RN Update notes dated 06/14/22 at 11:34 AM states, "the patient complained of having back and abdominal pain, very uncomfortable 10/10 (10 out of 10 on the pain scale), requesting pain meds. ... phone call to [name of doctor] message left to office."

ED RN Update notes dated 06/14/22 at 1:25 PM states, "the patient is still having abdominal pain and back pain and requesting pain medication, still waiting for [name of doctor] to call back. ... return phone call from [name of Doctor] ... Morphine 4mg IV and Zofran 4 mg order in place. 1:35 while attempting to obtain medications in the pyxis for patient, family came out from the room and stated that the patient is not responding ... CPR (cardiopulmonary resuscitation) ... initiated."

The patient was in moderate to severe pain on 06/14/22 from 2:30 AM until 1:25 PM, 10 hours and 55 minutes, with no evidence that pain management techniques or interventions were performed.

Upon interview on 07/29/2022, Staff #3 stated that the facility policy titled "Management of the Patient with Pain" was the policy in effect on 06/14/22.

On 07/29/22, Staff #3 confirmed that the patient was in pain on 06/14/22 from 2:30 AM through 1:25 PM, 10 hours and 55 minutes, with no adequate management of pain.

2) Upon review of Medical Record #10 on July 29, 2022, the following was noted:

The patient arrived to the ED on 07/29/22 at 10:17 AM. At 10:25 AM, the patient indicated a pain score of eight for pain to his/her abdomen. There was no evidence in the medical record that the RN performed a comprehensive pain assessment that includes pain quality, onset, duration, and aggravating and alleviating factors, as indicated in facility policy.

There was no evidence in the medical record that the RN and the patient mutually established an acceptable pain comfort goal, in accordance with facility policy.

On 7/29/22, Staff #3 stated that the policy titled "Pain Management Policy" was the policy in effect on 07/29/22. Staff #3 confirmed that there was no evidence in the medical record that the RN performed a comprehensive pain assessment. Staff #3 confirmed that there was no evidence in the medical record that the RN and patient mutually established an acceptable pain comfort goal.